6/4/2014 DSM 5. Webinars. Organization of the Manual
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1 DSM 5 WEBINAR PART 1 CBHA AND MARY THORNTON & ASSOCIATES, INC. Webinars General info on DSM and up through Bipolar Depressive Disorders through? Remaining plus (if time allows) new assessment tools, coding strategy. OASAS: DSM IV or 5 but mandatory DSM 5 January 2015 OMH: ICD 9; CAIRS, NIMRS will be able to use either starting late June Organization of the Manual Section 1: history and development of DSM 5 Section 2: criteria sets for the 19 major classifications also included in this section are the V and Z codes (medication induced movement d/orders and other conditions that t may be a focus of clinical i l attention) ti Section 3: assessment measures, a cultural formulation, an alternative DSM 5 model for personality d/orders, conditions for further study Appendices: cross walks to ICD 9 and ICD 10. Organized alpha and numerical 1
2 The Name and Other Changes DSM V no DSM 5: allows for continual updates which allows for the very rapid scientific advances being made so expect a 5.1, 5.2, etc. Goal was to move away from strict categorical structure and to incorporate dimensional measures to allow the clinician to better assess severity of symptoms (not just check yes or no) and to better measure outcomes. In DSM 5 there was an attempt to integrate some of these dimensional measures in order to support greater specificity in treatment decisions and evaluation of outcomes. The Name and Other Changes Dimensional measures were incorporated in some categories: Intellectual developmental disorder not simply an IQ measure but also now includes a dimensional assessment of adaptive functioning Merging gof substance abuse and dependence into one category of use with a scale of severity mild to severe Personality d/order work not accepted but described in Section 3 Optional dimensional measures: Chapter 3 of DSM including e.g. Clinician Rated Dimensions of Psychosis Symptom Severity Although incorporating dimensional measures DSM 5 still retains a primarily categorical approach. Organization Reorganization of the 19 major diagnostic classes Developmental life span begins with mental disorders usually diagnosed in infancy/early child In all categories diagnoses most associated with children are listed first Also an attempt to order according to those that are often or appear to be considered related. E.g. bipolar after schizophrenia; dissociative d/order in between trauma and somatic symptom 2
3 Use Its big Memorize some that you use most, use the pocket guide, and refer back often Meeting diagnostic criteria is becoming increasingly important with the advent of chronic health homes, outcome and risk based pricing, etc. Payers understand that many psychiatric disorders have characteristic courses and expected outcomes they will watch for these. Definition of Mental Disorder a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological or development processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual. Definition of Mental Disorder A diagnosis does not mean treatment is needed. Critical to medical necessity is the severity of symptoms, the subjective distress and the functional impact and sometimes other issues like the impact of the disorder on a medical condition. 3
4 Recording the Diagnosis DSM 5: there is a difference between principal DX and reason for visit. Critical when there are multiple diagnoses always list first reason for visit, if different from principle DX, and then other DX in descending order of importance. If the mental disorder is due to a medical condition, it must be listed first. This is true for both ICD 9 and 10. Provisional may be listed if there is diagnostic uncertainty but needs diligent attention Coding the Diagnosis DSM 5 and ICD 9 march in lock-step ( sort of) There is an ICD 9 code for each DSM however some diagnoses may use the same code because a more specific code not available. Orgs need to figure out how to manage this issue e.g. full narrative description in assessment? ICD 9 is a 3 to 5 digit number ICD 10 codes are listed parenthetically next to the ICD 9 code. DSM 5 used the ICD 9 code that most specifically matched the DSM diagnosis. See handout Coding the Diagnosis Some diagnoses have a 3 digit code, but most have 4 or 5 for greater specificity Follow guidelines in DSM where there are blanks in the code that must be filled in by the provider Sub-types and specifiers: Sub-types: mutually exclusive so instruction reads specify whether e.g. delusional disorder sub-typed based on content of delusion Specifiers: specify or specify if instruction to indicate provider should add additional information Some but not most ICD 9 codes (5 th digit) allow for the subtypes and specifiers provider must add after DX in narrative form 4
5 Coding the Diagnosis Diagnostic uncertainty: usually not billable V or Z codes which are usually not covered by themselves there are some exceptions unspecified mental disorder unspecified schizophrenia spectrum or other psychotic disorder Narrative e.g. provisional; explanation Coding the Diagnosis Other specified or unspecified Other specified: allows clinician to give reason why does not meet criteria in narrative with further versions of ICD will have ability to be specific through coding in some cases If not specified use unspecified diagnosis; use also when not sufficient information to make a more specific DX payers are beginning to watch these. Bye Bye Multi-Axial First found in DSM III but argued about ever since Axis II sometimes targeted for non-payment Axis III overlooked in developing plans of care (real problem with advent of aging population; chronic illness models; impact of meds on development of medical illness and vice versa) Axis IV socio-economic impact on severity and outcomes (never changes;? Real impact on course of illness) Axis V combo of both risk and functionality in a single number (arbitrary and inaccurate) 5
6 Bye Bye Multi-Axial Axis IV: use the V and Z codes located in ICD 9 and 10 located in Section 2 of DSM Axis V: WHODAS multiple versions functional assessment. Most providers already doing a risk assessment in body of assessment. WHODAS is not required but interesting the spotlight it now puts on functional assessment of the individual. WHODAS asks in areas not always seen in biopsychosocial assessment Changes in Neurodevelopmental D/orders Revamp of former chapter Disorders Usually First Diagnoses in Infancy, Childhood, or Adolescence First chapter according to new organization of DSM Mental retardation term gone. Replaced by intellectual disability or intellectual developmental disorder. Changes in Neurodevelopmental D/orders Intellectual Disabilities Communication Disorders Autism Spectrum Disorders Attention-deficit Hyperactivity Disorder Specific Learning Disorder Motor Disorders Other Specified Neurodevelopmental Disorder Unspecified Neurodevelopmental Disorder 319 (F70, F71, F72, F73) (F80.9, 80.0, F80.81) (F84.0) , (F90.0, 90.1, 90.2) , 315.1, (F81.0) 315.4, 307.xx (F82), (F98.4) (F88) (F89) 6
7 Changes in Neurodevelopmental D/orders Includes: Intellectual disabilities Communication disorders Autism Spectrum disorder Attention-deficit/Hyperactivity disorder Specific learning disorder Motor disorders Other neurodevelopmental disorders Intellectual Intellectual disability (Intellectual developmental disorder ICD 11 term) Despite name change and greater recognition of its multi-domain impact, still considered to be a mental disorder No longer a reliance on IQ as sole determinant of diagnosis or severity recognizes that the impairment in general mental abilities has an impact on adaptive functioning Adaptive functioning which can take into account social, conceptual/intellectual, and practical functioning is determinant of severity and need for external supports Specifiers for severity organized by domain: Conceptual : intellectual functioning Social: social and communicative behavior Practical: personal needs (including legal and health decisions, raising a family), independent employment, recreational - as move up scale level of supports needed, intensity, and length of time supports needed. Subtypes same: Mild, Moderate, Severe, Profound Communication Communication Disorders: deficits in language, speech and communication Language d/o: combines DSM expressive and mixed receptiveexpressive language d/o Speech/sound d/o former DSM IV phonological disorder Speech/sound d/o former DSM IV phonological disorder Child-onset fluency d/o former stuttering Social (pragmatic) communication d/o New for persistent difficulties in both verbal and non-verbal communication Note: this cannot be diagnosed if child also exhibits the restricted, repetitive behaviors, interests, and activities associated with autism spectrum d/o (see next slide) Maybe some individuals currently diagnosed with PDD? 7
8 Autism Autism Spectrum Disorder consensus that formerly four separate d/orders are actually a single condition with different levels of severity of symptoms in: Social communication and interactions Restricted, repetitive behaviors, interests, and activities (RBBs) Must have symptoms in both core areas Criterion A and B Autism Combines: autistic disorder, Asperger s disorder, pervasive developmental disorder, childhood disintegrative disorder. Specify level: DSM chart (pg 52) for Criterion A & B Level 3: requires very substantial support Level 2: requires substantial support Level 1: requires support Autism Specify if: w/wo intellectual impairment, language impairment; association with known genetic, environment, or medical factor; association with another neurobehavioral d/order; with catatonia Note for medical, environmental or genetic factors may require another code and may need to be coded first 8
9 Autism Criterion C and D: C: early onset which may have been masked by supports D: symptoms cause significant impairment in social, occupational, other functioning E: not better explained by another diagnosis ADHD Added to this chapter to reflect ADHD relationship to brain development Similar to DSM IV same 18 symptoms and same divide into categories of: inattention and impulsivity/hyperactivity 6 needed for children 5 needed for adults and adolescents 17 years + New examples added to assist with diagnosing across age ranges Cross-situational requirement strengthened to several in two or more settings e.g. home, school, work, friends, etc ADHD Onset criterion changed: Before: symptoms causing impairment before age 7 NOW: several present prior to age 12 Use specifiers that map to original sub-types (each with a different code) now describe the current presentation rather than a sub-type Combined: both A &B met for prior 6 mos Predominately inattentive: A but not B prior 6 mos Predominately hyperactive/impulsive: B but not A prior 6 mos Co-morbid diagnosis with Autism SD allowed 9
10 ADHD NO NOS: Other specified: do not meet criteria at this time; used when clinician wants to communicate reason why doesn t meet e.g. Other specified, with insufficient inattention symptoms Unspecified: doe not meet criteria but specific reason not specified or where there is insufficient information to make a more specific diagnosis These conventions hold true in other diagnostic categories Note there must be an accompanying clinically significant distress or impact on functioning Changes in Neurodevelopmental D/orders Specific Learning D/O Combines DSM IV s reading, mathematics, disorder of written expression, and learning d/order NOS Reflected concern that 3 separate distinct dx not justified Subtypes for reading, written expression and math separately coded Recognition that often not just one Specify current severity: mild, moderate, severe Changes in Neurodevelopmental D/orders Motor Disorders Included are: Developmental coordination disorder Stereotypic movement disorder Tourette s disorder Persistent motor or vocal tic disorder Provisional tic disorder Other and unspecified tic disorders Tic criteria standardized across all of these disorders: sudden, rapid, recurrent, non-rhythmic motor movement or vocalization May wax and wane in frequency, but have persisted for more than a year Stereotypic movement disorder: (helps to distinguish between it and body focused repetitive behavior d/orders in OCD Specify with or w/o self-injurious behavior Specify if associated with known medical, environmental or genetic d/order may need to be coded first Specify severity 10
11 Changes in Neurodevelopmental D/orders Other Conduct disorder moved to a new chapter Disruptive, Impulse-Control, and Conduct Disorders Elimination orders have own chapter Feeding disorders, e.g. pica moved to combined chapter with other eating disorders Separation anxiety disorder and selective mutism now in Anxiety Disorder chapter Reactive Attachment Disorder moved to Trauma and Stressor Related Disorders Changes in Schizophrenia Spectrum and Other Psychotic Disorders Schizotypal (Personality) Disorder (F21) Delusional Disorder (F22) Brief Psychotic Disorder (F23) Schizophreniform Disorder (F20.81) Shi Schizophrenia h i (F20.9) Schizoaffective Disorder (bipolar or depressive type) (F25.0, F25.1) Substance/Medication-Induced Psychotic Disorder see substance-specific codes included here but not discussed Psychotic Disorder Due to Another Medical Condition (with delusions or with hallucinations) , (F06.2, F06.0) Changes in Schizophrenia Spectrum and Other Psychotic Disorders Catatonia Associated with Another Mental Disorder (F06.1) Catatonic Disorder Due to Another Medical Condition (F06.1) Unspecified Catatonia (F06 1) Unspecified Catatonia (F06.1) Other Schizophrenia Spectrum and Other Psychotic Disorder (other specified or unspecified) (F28) 11
12 Changes in Schizophrenia Spectrum and Other Psychotic Disorders Generally arranged along a continuum of less to more severe Schizotypal Personality Disorder listed here but discussed in personality disorders Delusional disorder changes: Nonbizzare removed as adjective in Criterion A Somatic subtype edited to ensure those with a delusion regarding a physical defect diagnosed with body dysmorphic disorder now in OCD chapter Changes in Schizophrenia Spectrum and Other Psychotic Disorders For all: Specifiers only after 1 year duration of disorder: First episode, currently in acute episode First episode, currently in partial remission First episode, currently in full remission Multiple l episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Specify if with catatonia (use additional code) Specify current severity of delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mania symptoms Changes in Schizophrenia Spectrum and Other Psychotic Disorders Shared psychotic disorder gone rarely used and usually other diagnoses available Schizophrenia: Special treatment for bizarre delusions and special types of hallucinations gone Instead need two of the other listed symptoms in Criterion A Individual must now have at least one of three core positive symptoms: delusions, hallucinations, and disorganized speech Sub-types eliminated: determination that clinical utility and predictive validity poor no distinct Reponses to treatment or course of illness. Instead dimensional approach to rating severity of core symptoms See Clinician- Rated Dimensions of Psychosis Symptom Severity in Section III. 1-5 scale Schizo-affective disorder changes: Major change in duration of major mood episode concurrent with Criterion A of schizophrenia DSM IV: present for a substantial portion of the total duration of the active and residual periods of the illness DSM V: present for a majority of the total duration of the the active and residual portions of the illness 12
13 Changes in Schizophrenia Spectrum and Other Psychotic Disorders Delusional Disorder: no longer requirement that delusion be non-bizzare In addition to 1 year specifiers - specify type; specify if bizarre content; specify severity ( continuation of DSM IV) New demarcation between delusional and psychotic-types of body dysmorphic disorder in differentials No longer distinguishes i i shared delusional l If shared beliefs but does not meet criteria for delusional d/order then other specified used Catatonia: All require 3 catatonic symptoms out of the 12 listed Criteria described and diagnosed with specifier and separate code: With another mental disorder specifier for another diagnosis Due to another medical condition ( code first medical) separate diagnosis within context of medical condition Unspecified code first note other symptoms involving nervous and musculoskeletal systems Changes to Bipolar and Related Disorders Bipolar I Disorder (F31 series), (F31 series) Bipolar II Disorder (F31.81) Cyclothymic Disorder (F34.0) Substance/Medication-Induced Bipolar and Related Disorder see substance abuse section listed but not discussed here Bipolar Disorder Due to Another Medical Condition (F06.33, F06.34) Other Bipolar and Related Disorder (F31.89) Unspecified Bipolar and Related Disorder (F31.9) Changes to Bipolar and Related Disorders Mood disorders divided into bipolar and related disorders and depressive disorders with each in its own chapter Concern re: earlier detection New emphasis on changes in activity and energy and not just mood increase in goal directed d activity it or psychomotor agitation ti Criteria for Bipolar I, most recent episode mixed have been dropped and a specifier of with mixed features can be applied to episodes of mania or hypomania when depressive features present or alternatively for episodes of depression when features of mania/hypomania present 13
14 Changes to Bipolar and Related Disorders Other specified bipolar and related disorder: examples include Short duration hypomanic episodes and major depressive episodes Hypomanic episode without prior major depressive episode Specifiers for Bipolar and related disorders: Anxious distress specifier: DSM notes that anxiety has been reported as a prominent finding in many mental health settings. As such it is associated with higher suicide risk, non or longer response to Rx. Important to identify. Changes to Bipolar and Related Disorders Specifiers for Bipolar and related disorders: Anxious distress specifier: 2 out of 5 listed symptoms during majority of days of current episode. Specify in addition severity: mild, moderate, moderate-severe, severe E.g. severe 4 of 5 symptoms with motor agitation Mixed features replaces sub-type and can be applied to either bi-polar I or II Specify type Specify if in partial or full remission Specify severity: based on number of symptoms, severity of symptoms, and the degree of functional disability Thank You NEXT SESSION: PART 2 JUNE :30 AM 14
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